Health Assessment HESI Study Guide
Nursing Process ADPIE
Assess
Diagnose
Outcome identification
Planning
Implementation
Evaluation
History Taking and Documentations
Subjective – What patient says about their history
Collect Medical History
Collecting data, 4 types
o Complete Health data base
o Episodic or problem-centered database
o Follow up database
o Emergency Data base
History Taking Geriatrics
Minimize distractions
Speak clearly
Find main complaint
Get all medications, frequency and dose
Stethoscope
o Diaphragm for high pitched sounds: S1, S2, Aortic/Pulmonic,
Regurgitation/Murmurs
o Bell for low pitched sounds: Systolic murmurs, S3, S4, bruits
Interviewing Allergic Reaction
o While interviewing about allergies, make sure you ask what allergies
the patient may have, and what the reaction to these allergies is
o Nursing interventions for allergic reactions (insect stings, peanut
allergy, etc.)
History taking in child
o Health history adapted to include information specific for age and
developmental stage of child
o Biographic data
o Source of history
o Person providing information and relation to child
o Your impression of reliability of information
o Any special circumstances, e.g., use of an interpreter
o Reason for seeking care
o Children: history of present Illness
o Severity of pain: note effect on usual behavior, e.g., does it stop child
from playing?
o Associated factors, such as relation to activity, eating, and body
position
o Parent’s intuitive sense of problem often accurate; even if proven
otherwise, this gives an idea of parent’s area of concern
, o Parent’s coping ability and reaction of other family members to child’s
symptoms or illness
o Seizures: information from parents, onset, duration, etc.
Documentation of seizures.
Health adolescent interview
o Use the Adolescent: heeadsss psychosocial interview
˜Home
˜Education and employment
˜Eating
˜Activities
˜Drugs
˜Sexuality
˜Suicide and depression
˜Safety
o Review interviewing techniques: leading questions, open VS closed
ended questions, appropriate responses to patient (when crying, etc.)
Recall culturally appropriate care
o Native American Remedies
Seek healing from Shamans – medicine man/woman
o American Indian shamans uses traditional medicine bag which carry
necessary medicines.
Neurological
DTR assessment
o Deep Tendon Reflex use to detect neurologic response
o Elicit using percussion hammer: biceps, triceps, brachioradialis,
patellar, and Achilles
o normally these are 2+ and are equal bilaterally
Neurologic Assessment:
o To test cerebellar function of lower extremities by asking person to run
each heel down opposite shin
Mental Status: Any changes should be reported to the provider IMMEDIATELY
o A – Appearance (posture, movement, dress)
o B – Behavior (Conscious, Expression, Speech)
o C – Cognition (Orientation, Attention Span, Memory, learning)
o T – Thought Process (perception, anxiety, depression)
Older adults have slower response time
Abnormal Thought Process = BLOCKING
Mental Status Examination: Assesses mental health strengths and coping
skills and screens for any dysfunction.
Most suicides occur after beginning of improvement with increase in energy
levels
Delirium Tremens – Tachycardia, tachypnea, anxiety, nausea, shakes,
hallucinations, paranoia … (DTs start 12-36 hrs. after last drink)
Medication Review:
o MAOIs … Hypertensive Crisis with Tyramine foods
, o Nardil, Marplan, Parnate
o Need 2 wk. gap from SSRIs and TCAs to admin MAOIs
o Lithium Therapeutic Range = 0.5-1.5
o Phenothiazines (typical antipsychotics) – EPS, Photosensitivity
o Atypical Antipsychotics – work on positive and negative symptoms, less
EPS
o Benzos (Ativan, Lorazepam, etc.) good for Alcohol withdrawal and
Status Epilepticus
o Antabuse for Alcohol deterrence – Makes you sick with OH intake
o Alcohol Withdrawal = Delirium Tremens – Tachycardia, tachypnea,
anxiety, nausea, shakes, hallucinations, paranoia … (DTs start 12-36
hrs. after last drink)
o Opiate (Heroin, Morphine, etc.) Withdrawal = Watery eyes, runny nose,
dilated pupils, NVD, cramps
o Stimulants Withdrawal = Depression, fatigue, anxiety, disturbed sleep
Neuro Exams
o Two-point discrimination
o Graphesthesia
o Stereognosis
Neurostatus
o Stuporous: low state of consciousness, sleep like
o Syncope (neuro/cardiovascular)
Romberg Sign
o To test equilibrium, ask the patient to stand with arms at the sides, feet
and knees close together, and eyes open. Check for swaying, and then
ask him or her to close his or her eyes and maintain position.
o The examiner should be close enough to prevent falling if the patient
cannot stay erect. If he or she sways with the eyes closed but not when
the eyes are open (the Romberg sign), the problem is probably
proprioceptive (awareness of body position).
o If the patient sways with the eyes both open and closed, the neurologic
disturbance is probably cerebellar in origin.
Cranial nerves in eye assessment (function, how to assess)
PERRLA = Pupils Equal Round Reacting to Light and Accommodation
o Define accommodation
Babinski in adult
o When the Babinski reflex is present in a child older than 2 years or in
an adult, it is often a sign of a brain or nervous system disorder.
Disorders may include:
Amyotrophic lateral sclerosis (Lou Gehrig disease)
Brain tumor or injury
Meningitis
Multiple sclerosis
Spinal cord injury, defect, or tumor
Nursing Process ADPIE
Assess
Diagnose
Outcome identification
Planning
Implementation
Evaluation
History Taking and Documentations
Subjective – What patient says about their history
Collect Medical History
Collecting data, 4 types
o Complete Health data base
o Episodic or problem-centered database
o Follow up database
o Emergency Data base
History Taking Geriatrics
Minimize distractions
Speak clearly
Find main complaint
Get all medications, frequency and dose
Stethoscope
o Diaphragm for high pitched sounds: S1, S2, Aortic/Pulmonic,
Regurgitation/Murmurs
o Bell for low pitched sounds: Systolic murmurs, S3, S4, bruits
Interviewing Allergic Reaction
o While interviewing about allergies, make sure you ask what allergies
the patient may have, and what the reaction to these allergies is
o Nursing interventions for allergic reactions (insect stings, peanut
allergy, etc.)
History taking in child
o Health history adapted to include information specific for age and
developmental stage of child
o Biographic data
o Source of history
o Person providing information and relation to child
o Your impression of reliability of information
o Any special circumstances, e.g., use of an interpreter
o Reason for seeking care
o Children: history of present Illness
o Severity of pain: note effect on usual behavior, e.g., does it stop child
from playing?
o Associated factors, such as relation to activity, eating, and body
position
o Parent’s intuitive sense of problem often accurate; even if proven
otherwise, this gives an idea of parent’s area of concern
, o Parent’s coping ability and reaction of other family members to child’s
symptoms or illness
o Seizures: information from parents, onset, duration, etc.
Documentation of seizures.
Health adolescent interview
o Use the Adolescent: heeadsss psychosocial interview
˜Home
˜Education and employment
˜Eating
˜Activities
˜Drugs
˜Sexuality
˜Suicide and depression
˜Safety
o Review interviewing techniques: leading questions, open VS closed
ended questions, appropriate responses to patient (when crying, etc.)
Recall culturally appropriate care
o Native American Remedies
Seek healing from Shamans – medicine man/woman
o American Indian shamans uses traditional medicine bag which carry
necessary medicines.
Neurological
DTR assessment
o Deep Tendon Reflex use to detect neurologic response
o Elicit using percussion hammer: biceps, triceps, brachioradialis,
patellar, and Achilles
o normally these are 2+ and are equal bilaterally
Neurologic Assessment:
o To test cerebellar function of lower extremities by asking person to run
each heel down opposite shin
Mental Status: Any changes should be reported to the provider IMMEDIATELY
o A – Appearance (posture, movement, dress)
o B – Behavior (Conscious, Expression, Speech)
o C – Cognition (Orientation, Attention Span, Memory, learning)
o T – Thought Process (perception, anxiety, depression)
Older adults have slower response time
Abnormal Thought Process = BLOCKING
Mental Status Examination: Assesses mental health strengths and coping
skills and screens for any dysfunction.
Most suicides occur after beginning of improvement with increase in energy
levels
Delirium Tremens – Tachycardia, tachypnea, anxiety, nausea, shakes,
hallucinations, paranoia … (DTs start 12-36 hrs. after last drink)
Medication Review:
o MAOIs … Hypertensive Crisis with Tyramine foods
, o Nardil, Marplan, Parnate
o Need 2 wk. gap from SSRIs and TCAs to admin MAOIs
o Lithium Therapeutic Range = 0.5-1.5
o Phenothiazines (typical antipsychotics) – EPS, Photosensitivity
o Atypical Antipsychotics – work on positive and negative symptoms, less
EPS
o Benzos (Ativan, Lorazepam, etc.) good for Alcohol withdrawal and
Status Epilepticus
o Antabuse for Alcohol deterrence – Makes you sick with OH intake
o Alcohol Withdrawal = Delirium Tremens – Tachycardia, tachypnea,
anxiety, nausea, shakes, hallucinations, paranoia … (DTs start 12-36
hrs. after last drink)
o Opiate (Heroin, Morphine, etc.) Withdrawal = Watery eyes, runny nose,
dilated pupils, NVD, cramps
o Stimulants Withdrawal = Depression, fatigue, anxiety, disturbed sleep
Neuro Exams
o Two-point discrimination
o Graphesthesia
o Stereognosis
Neurostatus
o Stuporous: low state of consciousness, sleep like
o Syncope (neuro/cardiovascular)
Romberg Sign
o To test equilibrium, ask the patient to stand with arms at the sides, feet
and knees close together, and eyes open. Check for swaying, and then
ask him or her to close his or her eyes and maintain position.
o The examiner should be close enough to prevent falling if the patient
cannot stay erect. If he or she sways with the eyes closed but not when
the eyes are open (the Romberg sign), the problem is probably
proprioceptive (awareness of body position).
o If the patient sways with the eyes both open and closed, the neurologic
disturbance is probably cerebellar in origin.
Cranial nerves in eye assessment (function, how to assess)
PERRLA = Pupils Equal Round Reacting to Light and Accommodation
o Define accommodation
Babinski in adult
o When the Babinski reflex is present in a child older than 2 years or in
an adult, it is often a sign of a brain or nervous system disorder.
Disorders may include:
Amyotrophic lateral sclerosis (Lou Gehrig disease)
Brain tumor or injury
Meningitis
Multiple sclerosis
Spinal cord injury, defect, or tumor
